|§483.80 Infection Control|
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Based on observation, clinical record review and staff interviews, it was determined that the facility failed to ensure that infection prevention and control was maintained during tracheostomy care on one of two residents reviewed (Resident 250).
A review of Resident 250's diagnoses revealed Respiratory Failure, and Cerebral Infarction (Stroke).
A review of the progress notes dated January 14, 2021, at 6:39 p.m. revealed that Resident 250 was admitted to the facility with a tracheostomy (A surgical procedure that consist of making an incision on the front aspect of the neck and opening a direct airway through an incision in the windpipe). Further review of the same note revealed an order for as-needed suctioning and tracheostomy care every shift.
An observation of the tracheostomy care was conducted on March 11, 2021, at 8:40 a.m. with licensed Employee E8. The observation revealed that after Employee E8 checked Resident 250's oxygen saturation (Measures the number of red blood cells), Employee E8 cleaned the bedside table, removed his gloves, and set up the dressing, gloves, and other things that will be used for suctioning and tracheostomy care. Employee E8 opened a sterile glove package, picked up the sterile gloves with bare hands, stretched it then put them on. Employee E8 used his left hand to touch unsterile areas/surfaces which includes the suction knob while suctioning and used his right hand to touch the suction tube. At 8:52 a.m. Employee E8 used his left hand to insert the tip of the suction tube inside the cannula then proceeded with suctioning the resident. After suctioning, Employee E8 changed gloves, removed the gauze with phlegm on the resident's tracheostomy site then threw it on the garbage receptacle then changed gloves. Employee E8 cleaned the surrounding of the resident's tracheostomy site with gauze, changed gloves then cleaned it again with a Qtip. After changing gloves, Employee E8 picked up the sterile disposable inner cannula and placed it on the resident's tracheostomy then cleaned the phlegm of the tracheostomy mask then placed it on the resident's neck. After changing gloves, Employee E8 rechecked the resident's oxygen saturation, removed all used dressings and packages then performed handwashing.
During the entire observation of suctioning and tracheostomy care, Employee E8 was observed changing gloves a total of six times but did not observed performing any hand hygiene in between changing of the gloves.
An interview was conducted With Employee E8 on March 11, 2021, at 9:00 a.m. and was made aware of contaminating the sterile gloves used for suctioning and the tip of the suction tube. Employee E8 was also made aware of the missed hand hygiene in between changing gloves, the employee acknowledged the surveyor.
The above was conveyed to the Assistant Director of Nursing on March 11, 2021, at 1:00 p.m.
The facility failed to ensure that infection control and prevention were maintained during Resident 250's tracheostomy care.
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 7/10/20, 6/18/20, 5/7/19.
| ||Plan of Correction - To be completed: 05/03/2021|
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
All residents requiring suctioning via an endotracheal tube have the potential to be affected. Regarding resident 250, a full respiratory assessment was conducted. Respiratory assessment, including a full set of vital signs were implements every shift x 72 hours. Physician made aware; Respiratory Therapist was educated.
Tracheostomy policies were reviewed and revised as needed. In-services were provided to appropriate staff immediately. Facility wide education initiated for Respiratory Therapist, professional nurses regarding tracheostomy care, including suctioning and infection control principles.
DON, or designee, will audit for appropriate tracheostomy care, including suctioning. Audits will occur daily x2 weeks, weekly x2 and monthly x2, on all shifts. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee